Provider Demographics
NPI:1841586823
Name:ATENCIO-BACAYON, JENNIFER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:ATENCIO-BACAYON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ATENCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2296 PLYMOUTH PL
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1229
Mailing Address - Country:US
Mailing Address - Phone:917-226-3391
Mailing Address - Fax:
Practice Address - Street 1:75 PLANDOME RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-2303
Practice Address - Country:US
Practice Address - Phone:917-226-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical